Rocking the cradle

March 3, 2005

Posted on Sun, Feb. 27, 2005

Rocking the cradleA growing number of children are being diagnosed with manic depression, which affects about 2.3 million AmericansBy Sandra G. BoodmanWashington Post

Washington Post photos

Recent books on bipolar illness in children reflect growing popular interest in the disorder, which seems to be growing among children.

From the time her son was born, Jennifer DeWeese said, she suspected something was wrong. As an infant he cried inconsolably and slept mostly in hour-long snatches. At 3, he was always irritable and had prolonged tantrums triggered by the slightest change in his routine. A therapist told his mother he was emotionally disturbed and suggested she read a popular book about childhood bipolar disorder. A year later a child psychiatrist in Virginia Beach, Va., made the diagnosis: the 4 1/2 -year-old was manic-depressive.

A few months later, when his even-tempered sister grew moody and volatile, DeWeese took her to the same psychiatrist. They sat down with DeWeese’s well-thumbed book about bipolar children and went through its symptom checklist. Based largely on those results and the family’s history – DeWeese said she learned during her divorce that the children’s father had been diagnosed as bipolar in high school – the psychiatrist told DeWeese her 5 1/2 -year-old daughter was bipolar, too.

“I feel relieved to know there is something causing their symptoms and something we can do about it,” said DeWeese, 34. She is convinced, she said, that her children’s problems are inherited, not a reaction to their father’s permanent departure, a bitter divorce marked by allegations of spousal abuse, a bankruptcy that resulted in the loss of the family’s house and car, DeWeese’s frequent hospitalizations for kidney disease and the arrival of a new stepfather.

Now 6 and 8, DeWeese’s son and daughter exemplify a trend that is roiling mental heath: the burgeoning number of children diagnosed with bipolar illness, also known as manic depression, which affects about 2.3 million Americans.

The illness, which is usually diagnosed in adolescence or early adulthood, is a serious and disabling mood disorder that, if untreated, carries an elevated risk of suicide. Sufferers typically cycle between manic highs, in which they can go for days without sleep in the grip of grandiose delusions, and depressive lows, marked by a preoccupation with death and feelings of worthlessness.

There is no test for bipolar illness, which is believed to result from a poorly understood interplay between genetics and environment. Although the disease runs in families, according to the National Institute of Mental Health, most children with one bipolar parent won’t develop the illness. Their risk is about 10 to 15 percent compared with 1 percent among the general population. Institute officials say there are no reliable statistics on the risk posed by having two bipolar parents.

Statistics documenting the increase in pediatric bipolar diagnoses are elusive, but a dozen psychiatrists and child psychologists interviewed for this story say there have been sharp increases in the past decade. Before that, the illness was rarely diagnosed before adolescence.

Although definitive answers about the disorder in children await the results of several studies currently under way, many doctors aren’t waiting. Proponents of early intervention say that aggressive treatment can limit the damage of untreated mental illness.

As a result, some preschoolers barely out of diapers are being treated for bipolar disorder with powerful drugs, few of which have been tested in children.

At Dominion Hospital in Falls Church, Va., which houses the Washington area’s largest inpatient psychiatric unit for children, psychiatrist Gary Spivack said patients as young as 4 have been hospitalized, sometimes for a few weeks at a time. “They’re just so out of control that almost nothing else has the power to do it,” Spivack said, who adds that many were being raised in highly dysfunctional homes.

But some experts say the surge in diagnoses is a dangerous fad – one critic called it “psychiatry’s flavor of the month” – a decision too often based on skimpy evidence, cursory evaluations and incorrect assumptions.

These children are troubled, critics say, but most don’t meet psychiatry’s official diagnostic criteria for the lifelong psychotic disorder.

“Labeling severe tantrums in toddlers as a major mental illness lacks … validity and undermines credibility in our profession,” warns Jon McClellan, associate professor of psychiatry at the University of Washington, in a forthcoming article in the Journal of the American Academy of Child and Adolescent Psychiatry. “The illness has become a cultural phenomenon, adorning the cover of Time magazine and headlining national news broadcasts.”

It has also spawned numerous Web sites and more than a dozen books mostly aimed at parents. Two of them are written for children, including “Matt: The Moody Hermit Crab,” whose main character winds up in a mental hospital after he tries to stab his family with a kitchen knife.

Joseph Biederman, a professor of psychiatry at Harvard and one of the most forceful advocates of the aggressive treatment of preschoolers, thinks bipolar disorder has been “severely underdiagnosed” in children.

He likens the criticism he has encountered to the outrage that greeted Galileo’s challenge to the notion that the Earth was the center of the solar system.

“The diagnosis is controversial only because it has been assumed not to exist,” said Biederman, chief of pediatric psychopharmacology at Massachusetts General Hospital.

In his view there are clear-cut symptoms that distinguish bipolar disorder from attention-deficit hyperactivity disorder, with which it is often confused, or other problems. He said studies have found that bipolar children are severely agitated and aggressive, grandiose (they tell the teacher how to run the class or think they have the same authority as a parent), hypersexual (one report cites children who imitate sexy rock stars or use explicit language) and experience very rapid mood swings, sometimes several times an hour, during which they can become explosively angry.

“These are very disturbed children that are a nightmare to treat,” said Biederman, who estimates he has seen nearly 100 of them: 3-year-olds so assaultive their parents feared for their safety; 5-year-olds who downloaded pornography from the Internet; and preschoolers who literally tore apart his office during a consultation.

“These symptoms are not subtle,” he said.

Maybe not, said Washington psychiatrist and lawyer Wayne Blackmon, but they are also suggestive of a host of other problems: depression, anxiety, abuse, attention-deficit hyperactivity disorder or a behavioral problem such as conduct, explosive or oppositional defiant disorder.

Resistance to using medications has softened, experts say, for a variety of reasons: aggressive marketing by pharmaceutical companies; the skyrocketing use of drugs in preschoolers to treat attention-deficit hyperactivity disorder and depression; a lessening of the stigma surrounding bipolar disorder spurred by the accounts of celebrities such as Ted Turner and Jane Pauley; and an insurance system that rewards brief appointments to check medication over time-consuming evaluations and therapy.

Telling the difference

Bipolar illness, also called manic depression, is a chronic and serious mood disorder that affects men and women equally. Medications such as lithium are used to control the sharp swings between manic highs and depressive lows which, if untreated, can lead to suicide.

According to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, published by the American Psychiatric Association, manic episodes must last at least four days. Three symptoms must be present including grandiosity, irritability, sharply decreased need for sleep (feeling rested after three hours, for example), hypersexuality, racing thoughts or extreme distractibility.

Depressive episodes must last two weeks and reflect a change in how the person was functioning. Five symptoms must be present: irritability, fatigue, feelings of worthlessness, insomnia, significant unintended weight loss or gain, and suicidal thoughts. Many other psychiatric and physical illnesses can mimic bipolar illness in children and should be considered before a diagnosis is made, experts say. They include:

•Depression

•Conduct disorder

•Oppositional defiant disorder

•Generalized anxiety disorder

•Intermittent explosive disorder

•Panic disorder

•Post-traumatic stress disorder

•Obsessive-compulsive disorder

•Attention-deficit hyperactivity disorder

•Tourette’s syndrome

•Metabolic disorders including overactive thyroid

•Brain tumor or brain damage

•Temporal lobe epilepsy

•HIV

Sources: DSM-IV, American Academy of Child and Adolescent Psychiatry, Child and Adolescent Bipolar Foundation

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